216 White Dove Way Lot 120
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002862 Tax PIN/EH #: 5820-64-9480.12MB
Billed To: Mitch Buie Subdivision Info: White Dove Acres Lot # 12
Reference Name: Location/Address: White Dove Way -27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3531
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with
Article I l of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type Af)ca:�. #People 4 #Bedrooms 4 #Baths _-_:S
Dishwasher: 12111, Garbage Disposal: ❑ Washing Machine:[?" Basement w/Plumbing: 13'*" Basement/No Plumbing: ❑
Commercial Specification: Facility Type �_ •#People #People/Shift #/Seats Industrial Waste: ❑
Lot Size +` t S Type Water Supply (N ` Design Wastewater Flow (GPD)LIC) Site: New 0""" Repair ❑
System Specifications: Tank Size { W GAL. Pump Tank GAL. Trench Width p Rock Depth Linear Ftk-�
Other:ls-1 tt?it L.,Xr—s
I
Required Site Modifications/Conditions: rASTAUL— �'')1 1�' Sp e:>� C e VaC-�p tbC fZ��
E�
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 "B LOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final ins ion of this
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.****
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Environmental Health Specialist's Signature: _
05/99 (Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990002862 Tax PIN/EH #: 5820-64-9480.12MB
Billed To: Mitch Buie Subdivision Info: White Dove Acres Lot # 12
Reference Name: Location/Address: White Dove Way -27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3531
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatme t and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWAT A FOR A PERIOD OF FI YEARS.
Environmental Health Specialist's Signature: Date: b
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall.4n N AY -betaken as a guarantee that the system will function satisfactorily for any
given period of time.
�.
rae,J T -
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
1�TI✓ ��= L,9c.
Date:
:/
I
APPLICATION 1`011 SITE EVALUATION/lhll'l1OVDIE%4T pr-,
Davie County Health Department
En vironm ental Hea/th seciian
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-11760
-�Lln� JUL 2 82003
EIMR�A E COUNW
***IMPORTANT*** TRIS F.PPLICATION CANNOT BE PROCESSED UNUSS ALL TILE REQUIRED ^�
INFORMATION IS PROVIDED. Refer to the INFORMATION DULLRTIN Lor instruct:ion:i.
Name to be Billed a 1 ( �� Contact Person 410:i11ci D✓ r< --V-%.
Mailing Address, t�;nl�dZ Home Phone
City/state/zipPcaje&� U—dl_ /Ut,� a.70Lit) Business Phone
2.
Name on Permit/ATC if Different than Above
Mailing Address
City/State/X.ip
3.
Application For: Site Evaluation
improvement Permit/ATC ❑ BoL•li
4.
System to Service:'IkHouse ❑ Mobile home
❑ BusineSs ❑ Industry ❑ Other
S.
Type system requested: Co::ventional ' ❑ conventional modified ❑ iunovaL•ive
6.
If Residence: tl People _ u
t
Bedrooms y 11 Bathrooms 3 _
Dishwasher ❑Garbage Disposal ,lashing Machine
^RBasemont/Plwnbing ❑Basement/No Plumbing
7.
If Businass/Industry /ether: verify type
it People It Sinks,
tt Commodes p showers
N Urinals Ir Water Coolers
IF FOODSERVICE: 0 Seaty Estimated Water Usage (gallons per day)
8.
Type of water supply: ❑ County/City
'R Well ❑ Conununity
S.
Do you anticipate additions or UpalisiouS of the facility
(his system is iUleuded (o ScrYe? ❑ Yes Nu
ifyes,vvhat type?
***IAIPOItT4NT***CLIENTS MUST COUPLE TE• THE ACQUIRBD PKOPLICrY INFORMNI-ION REQUESTED
BELOW. Culler a PLAT or SITE PLAN AfUSTBESUTAN/TTED by the client vvLth I'll IS A1111L1CATION.
Property Dirliensions: U L{1� k U X) Y (o I c) whi
n� MIMCNONSS,(,fi-mnt 11luclisville) to Pl ON'lll'1':
'rax office PIN: 41 S •2ci - G V - 9 ��'�� . / ;2- (Irl LS1 n j "'J l `/1 lMtl G-. AQS7k
Property Address: Road Name t .4 � 21 4�e �� " l r�t►t 0 � �(�✓
ci tylzip ma kb (j� l lw -7 a vim- CA-�bte,
T'
If in a Subdivis1io^ti provide infurnlatic it, as follows:
Scctioll: Block: _ Lot: j _ J
Date ]tunic corners flagged:
This is to certify that the information pruvided is correct to the best of Iny knowledge. I understand Iliat any perniil(s)
issued hereafter are subject to suspension or revocatiou, if the site plans or intended use change, or if (lie information
submitted in this application is falsified or changed. I, also, attderstand that 1 rttli responsible fur all charges incurrelf fi• ill
this application. I, hereby, give consent to (lie Authorized Representative of Ute Davie County IIcalila Dcparlittcul
to cuter upon above described property located in Davie County and omied by
to conduct all testing procedures as ncccssary to determine (lie sitelwiitability.
DATE 7' 2SIGNATURE X /�
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include al] of the following: Existing :and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Datc(s):
Client Notification Date:
ruS:
Sign given Account No. -1:>— K- (lp_--)--
Revised DCIID (05/03 Iuvolce No.
17,4 'T J_3
APPLICANT INFORMATION
Account #: 990002862
Billed To: Mitch Buie
Reference Name:
Proposed Facility: Residence
Water Supply: On -Site Well
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
Property Size:
PROPERTY INFORMATION
Tax PIN/EH #: 5820-64-9480.12MB
Subdivision Info: White Dove Acres Lot # 12
Location/Address: White Dove Way -27028
see map Date Evaluated:
Community
Evaluation By: Auger Boring Pit
Public
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
LEGEND
Landscaae Position
EVALUATION BY:
OTHER(S) PRESENT:
R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope
CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope
Texture
S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt
SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
Moist
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
Wet
NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic
Structure
SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralogy
1:1, 2:1, Mixed
Notes
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification - S(suitable), PS (provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
DCI1D 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT / /"7-0 O
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990000974 Tax PIN/EH #: 5820-64-9480.12
Billed To: James & Hanna Brown Subdivision Info: White Dove Acres Lot # 12
Reference Name: James & Hanna Brown Location/Address: White Dove Way -27028
Proposed Facility: Residence Property Size: 5.05 Acres
ATC Number: 2325
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with
Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type Hol�s� #People 3 #Bedrooms #Baths �l _
Dishwasher: 13� Garbage Disposal: EK— Washing Machine: 2<- Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industtrriall Waste:
5 ❑
Lot Size os kASType Water SupplAl l- L -- Design Wastewater Flow (GPD) _ Site: New �' Repair ❑
System Specifications: Tank Size ( WaAL. Pump Tank h AL. Trench Width-- � � Rock Depth Linear Ft.l000t
Other: ( �►STQIP��Tt�aX,fpS , I�Isi"at.l_ L_1�1�59 rE9-C. M,1„� .
Required Site Modifications/Conditions: ' )1 Vr�T soup c-- WNTOizGP -50 bF% CP- , kea !Ut P -o*—
IMPROVEMENVOPERATION PERMIT LAYOUT - APPROVED E LUENT FILTER RISERS) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Dav e County Health Department for final inspection of this
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the installation. Telephone # is (336)751-8760.****
POMP
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ZON Z" 1-►►�� cR L
(� TOL, 1i El0
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172+ J
Environmental Health Specialist's Signature: ^ .—gate: 2 14P O-0
2 1 Lill Zr]
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Account #: 990000974
Billed To: James & Hanna Brown
Reference Name: James & Hanna Brown
Proposed Facility: Residence
ATC Number: 2325
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5820-649480.12
Subdivision Info: White Dove Acres Lot # 12
Location/Address: White Dove Way -27028
Property Size: 5.05 Acres
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWAT NST TION IS VA FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: ate:
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
has been installed in compliance with Article I 1 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given period of time.
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Date:
Y
p
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department FEB Q �OJJ
Environmental Health Section
P.O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
***nWORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1.
Name to be Billed ,)Q 1�1111e-2S b % AIGI r)(3- (i.
13rbL0 )contact Person 6(ZrVV1 ��
(
--T
M
f -7'j(1�
/ /�
Mailing address `) Y�_.( )� a
Home Phone -,53q
`)
City/state/ZIP �)qj� J NQ'
Business Phone 751-5�(o'o
2.
Name on Permit/ATC If Different than Above
Mailing address
City/state/Zip
3.
Application For: ❑ Site Evaluation
❑ Improvement Permit/ATC
Both
Ix
4.
system to service: �House ❑ Mobile Home
❑ Business ❑ Industry 11Other\s.
If Residence: #People �_
# Bedrooms # Bathrooms
�Cryl�O)
Dishwasher Garbage Disposal l Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Industry/Other: specify type
# Cosaiodes
# showers
# Urinals
# People # sinks
# Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of Water supply: ❑ County/City] Well ❑ Community
a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes XNo
If yes, what type?
***IMPORTANT** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION.
Property Dimensions: ,q. o s n C. WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax Office PIN: # ob — 9 8o (O o
Property Address: Road Name L c,tU
City/Zip } ,Y 1,n x Q Q 4' s� C 4 _
If in a Subdivision provide information, as follows: �2J2-la
Name: ( t
Section: Block: Lot: 1CQ DaMTroperty Flagged:
This is to certify that the information provided is correct to the best of my knowledge. I understa that any permit(s)
issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information
submitted in this application is falsified or changed I, also, understand that 1 am responsible for all charges incurred from
this application. I, hereby, give consent to the Authorized Representative of the Davie County Hea h Department
to enter upon above described property located in Davie County and owned by
to conduct all testin procedures as necessary to determine the site suitability.
DATE O SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN
property lines and dimensions, structures, setbacks, and septic loc,
Revised DCHD (07/99)
all of the following: Existing and proposed
Site Revisit Charge
Date(s):
I Client Notification Date:
EHS•
Account No. i7l
Invoice No. 02 /to
Pooh D
a
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O
i
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59. Si
S 52.21':
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V CI 4
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0' EASEMENT
6
7
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50' EASEMENT
9
10
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uo
MAP SHOWING DIVISION OF:
WHITE DOVE ACE
MAY 12, 1997
REVISED: JULY 21, 1997
WXMNG COMPANY 300 150 0 300 600
Y CHURCH ROAD
4 K ' 2702.3
492-3616 SCALE IN FEET N
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990000974 Tax PIN/EH #: 5820-64-9480.12
Billed To: James & Hanna Brown Subdivision Info: White Dove Acres Lot # 12
Reference Name: James & Hanna Brown LocatioNAddress: White Dove Way -270 8
- Proposed Facility: Residence Property Size: 5.05 Acres Date Evaluated: Z lS c�
Water Supply:
Evaluation By:
On -Site Well Community
Auger Boring Pit
Public
Cut
FACTORS
1
2
3 4 5 6 7
Landscape position
Slope %
tru
HORIZON I DEPTH
O -1
Texture group
C_
Consistence
fir. 55,5 P
Structure
I<
G
Mineralogy
J
HORIZON II DEPTH-
Z
Texture groupCr*
C
S
Consistence
F'
$
Structure
43 k
<A V_
ti
Mineralogy
, I 1
1 •-1
Mt»
HORIZON III DEPTH
Z4 - 4
Texture group
C
Slip -
Consistence
Structure
k
Mineralogy1
HORIZON IV DEPTH
+
Texture group$�
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE 1
O .
SITE CLASSIFICATION: IJ
LONG-TERM ACCEPTANCE RATE:
REMARKS:
`amu tJ .Q
EVALUATION BY: �' t �
OTHER(S) PRESENT: `— ^YT�'``^
T
LEGEND
Landscape Position
R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope
CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope
Texture
S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt
SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
Moist
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
Wet
NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic
Structure 1
SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralogy
1:1, 2:1, Mixed
Notes
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
DCHD 05/99 (Revised)
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